There was insufficient information available to establish the precise cause of the vessel sinking. It could not be determined with certainty whether the urchin drag was deployed over the stern to act as an anchor had the boat lost power; try a test tow; or tighten the lay of the cable on the drum. The engine hatch cover was too large and unwieldy to exit the wheelhouse without assistance. However, the cover was found ashore. This suggests that it had been opened and stowed on deck to provide access to the main engine, perhaps following engine failure. As the vessel was close to shore while passing through Sand Cove, New Brunswick, the urchin drag may have been deployed over the stern to act as an anchor. It is not likely that the operator would have deployed the drag to try a tow because he was familiar with the area, having dived for urchins there, and knew the bottom to have many obstructions. In addition, the operator was likely aware that the cable was only wrapped hand-tight on the winch and would present the risk of becoming snarled once stress was placed on it. The cable had been rove onto the warping drum by hand, and thus was not as tight as would be desired for fishing. The cable must be guided onto the drum under tension to avoid having it tighten to such a degree that the outer wraps become drawn into the inner wraps. The engine controls were found in the slow astern position, and the ignition key in the ON position. This suggests that the engine was restarted at some point after the drag was deployed. It is probable that the vessel was backing up to recover the drag, when the cable became snagged on an obstruction on the sea floor. When the cable became snarled on the winch drum, the vessel would have been tethered on a short scope and unable to pay out any more slack. With little room to manoeuvre, the Lo-Da-Kash would have been more susceptible to the effects of wind and waves. The lack of any distress calls received suggests that the events leading up to the sinking transpired very quickly.Analysis There was insufficient information available to establish the precise cause of the vessel sinking. It could not be determined with certainty whether the urchin drag was deployed over the stern to act as an anchor had the boat lost power; try a test tow; or tighten the lay of the cable on the drum. The engine hatch cover was too large and unwieldy to exit the wheelhouse without assistance. However, the cover was found ashore. This suggests that it had been opened and stowed on deck to provide access to the main engine, perhaps following engine failure. As the vessel was close to shore while passing through Sand Cove, New Brunswick, the urchin drag may have been deployed over the stern to act as an anchor. It is not likely that the operator would have deployed the drag to try a tow because he was familiar with the area, having dived for urchins there, and knew the bottom to have many obstructions. In addition, the operator was likely aware that the cable was only wrapped hand-tight on the winch and would present the risk of becoming snarled once stress was placed on it. The cable had been rove onto the warping drum by hand, and thus was not as tight as would be desired for fishing. The cable must be guided onto the drum under tension to avoid having it tighten to such a degree that the outer wraps become drawn into the inner wraps. The engine controls were found in the slow astern position, and the ignition key in the ON position. This suggests that the engine was restarted at some point after the drag was deployed. It is probable that the vessel was backing up to recover the drag, when the cable became snagged on an obstruction on the sea floor. When the cable became snarled on the winch drum, the vessel would have been tethered on a short scope and unable to pay out any more slack. With little room to manoeuvre, the Lo-Da-Kash would have been more susceptible to the effects of wind and waves. The lack of any distress calls received suggests that the events leading up to the sinking transpired very quickly. Stability at the Time of the Occurrence Lightship and Departure Conditions The TSB conducted a post-occurrence stability analysis, the details of which are contained in a separate stability report.4 Various conditions were prepared to reflect the loading of the Lo-Da-Kash during its voyage and at the time of the occurrence, based on the number of crew and their effects, the estimated consumables and the fishing gear on board. The stability of the Lo-Da-Kash for these conditions of loading was assessed and compared with the criteria contained in the STAB4 stability standards. The assessment took into consideration the effect created by the wind, the ice accretion, the towing cable acting at the block at the top of the A-frame, and a possible flooding of the well. In the lightship condition, the metacentric height (GM) was determined to be 2.64m, which is well above the minimum of 0.35m required by STAB4. The freeboard to the freeing ports and to the gunwale was 0.16m and 0.86m, respectively. In the departure condition from Maces Bay, the stability of the vessel was such that the area under the righting arm (GZ)curve at angle of heel between 0 and the angle of downflooding (20) exceeded the criteria of STAB4. However, the range of positive stability was limited to about 20, due to the submergence of the gunwale at that angle, with the consequence of downflooding the after well. There is no explicit criterion for a minimum range of positive stability in STAB4, but there is a criterion for the area under the GZcurve between 30 and 40, which was not met. In the departure condition, the freeboard in still water in way of the freeing ports was 0.08m. In the lightship condition, the installation of the A-frame, the deck winch and the boom winch reduced the GMof the vessel from 2.94to 2.64m. In the departure condition, this installation reduced the range of positive stability from 23.6 to 20 and the freeboard from 0.13to0.08m. Wind and Icing Considerations During the transit between Maces Bay and Campobello Island, the Lo-Da-Kash was exposed to winds six points on its starboard bow. The relative direction of the wind in conjunction with cold temperatures caused freezing spray and icing. Under such conditions, ice would accumulate on the windward side (starboard side) of the vessel. This is consistent with the vessel developing an angle of heel of under one degree to starboard- heel that would not significantly affect the vessel's stability. On the return trip, with the wind abaft of the beam, ice accretion was minimal due to the relative wind speed and seas, and the initial starboard list was maintained. In the absence of precise information, the rate, quantity, and location of ice accretion aboard the Lo-Da-Kash was estimated using the prevailing meteorological and oceanographic conditions, during the voyage and at the time of occurrence. According to the Mertin's icing diagram,5 with wind force6 (22to 33knots) on the Beaufort scale, air temperature of -10C and seawater temperature of 4C, the rate of ice accretion during the estimated six-hour voyage was considered to be moderate, generating an accumulation of 1to 1.5cm. Icing allowances were included in the stability analysis using the estimated values mentioned above. In the case of the Lo-Da-Kash, the icing increased the weight of the vessel by a maximum of 1.05tonnes (1.03long tons), reducing the freeboard by less than 0.03m and creating a maximum starboard list of less than one degree. The stability was adversely affected by the rise of the centre of gravity of the vessel with accumulated ice, but the area under the GZcurve was within the criteria set forth in STAB4 at an angle of heel of between 0 and 30. The range of positive stability was limited to about 19, again due to the submergence of the gunwale. The stability was less than the criteria set forth for the area under the GZ curve between 30 and 40. The vessel was not equipped with the means to remove the ice. Effect of Fishing Gear In 1965, the International Maritime Organization (IMO) Sub-committee on Safety of Fishing Vessels discussed the problem of whether the forces induced by fishing gear were dangerous for the stability of fishing vessels. The IMO has recognized that the pull from fishing gear may result in dangerous heel angles, but has not yet established any special stability criteria for fishing vessels subject to the action of fishing gear.6 The maximum forces occur when its rigging gets caught on some underwater obstacle. The assessment of the stability of the Lo-Da-Kash under the effect of fishing gear was therefore considered necessary. The following situations were considered: The fishing gear was deployed overboard, acting as an anchor, or the vessel was dragging at constant speed on a straight course with the cable running out on the winch via the top block on the A-frame. The vessel was towing the drag or was backing up to recover it and the cable became fouled on an underwater obstacle on the ocean floor. The vessel was trying to free the fouled cable from the ocean floor by the thrust of the propeller or the pull of the cable winch. The force acting on the cable is greater when the vessel is dragging, due to the friction of the fishing gear on the ocean floor, compared to when the drag is simply deployed overboard acting as an anchor. When the fishing gear is deployed, the axis of the cable may not be in the centre plane of the vessel, generating a heeling moment that will increase with the angle of heel. The pull in the towing cable was acting at the top block of the A-frame. In a dragging condition at a constant speed on a straight course, the resultant pull in the cable was estimated to be 9.96kilonewtons(kN), or one long ton. The results of the stability analysis show that the corresponding trimming moment would create a trim by the stern of 0.64m. The area under the GZcurve is consistent with the stability criteria of STAB4 only between 0 and 30, and the range of positive stability would be limited to about 20, corresponding to the submergence of the gunwale and flooding of the well. It is likely that the vessel was not towing, because the short remaining length of cable found after recovery was insufficient for a proper tow. When the urchin drag of the Lo-Da-Kash was found, the remaining length of cable between the fouling point and the parted end was about equivalent to the height of the top block above the ocean floor. In this situation, any attempt to release the fouled cable from the ocean floor by the thrust of the propeller, by the cable winch, or by the use of the vessel's inertia would have been dangerous. The results of tensile tests carried out on the towing cable showed a breaking strength of approximately 88.74kN (9.05tonnes).7 The heeling moment generated by a force of this magnitude, acting at the top block with a short cable, would be such that, at an initial angle of heel of about 6, it would be greater than the maximum righting moment. At that point, the vessel would incline very rapidly and be prone to capsizing. In the case of an open-construction type vessel (Cape Islander), the gunwale would become submerged, leading to flooding of the well. Loss of Reserve Buoyancy In this instance, the vessel's range of stability was limited to 20. At this angle, the vessel would be prone to shipping and retaining water on deck. The cumulative effect of this, together with the liquids in the slack tanks, generated free surface effect further exacerbating the situation. Downflooding ensued through the openings at the well deck until all reserve buoyancy was lost and the vessel sank. Requirement for Stability Data Currently, there is no requirement for small uninspected fishing vessels, such as the Lo-Da-Kash, to submit trim and stability data to TC for information, review, or approval. The Board has repeatedly expressed the concern that the stability characteristics of most small fishing vessels are not formally assessed and, consequently, their safe operation is compromised. In November2003, the Board issued two recommendations to TC(M03-05 and M03-06), calling for the assessment/verification of stability for new and existing small inspected fishing vessels. In2005, following the loss of the Ryan'sCommander and concerned that, in the absence of meaningful action to address past recommendations, fishers continued to be placed at undue risk, the Board issued another recommendation (M05-04) calling on TCto immediately implement recommendations M03-05 and M03-06. (See Safety Action Taken section for subsequent actions.) While these recommendations were made in relation to small inspected fishing vessels (with a gross tonnage of 15to150), the principles also apply to small uninspected fishing vessels (with a gross tonnage of under15) given that the risk associated with their operation is similarly high. Periodic Verification of Stability Data Owners of commercial vessels are required to report modifications toTC. In addition, where there is change of ownership of a registered vessel, or modifications require that the vessel's registration information be changed, then TCis notified by the Registrar of Ships as a matter of course. However, in many cases, such as the Lo-Da-Kash, commercial vessel owners simply make structural modifications without notifying any authority. Frequent changes to the management and operation of the fisheries mean that fishing vessel modifications are an ongoing reality. These modifications, which may adversely affect a vessel's transverse stability, are often carried out without any evaluation by a naval architect or assessment by a TCinspector. In the absence of such an assessment, operational decisions may be based on imprecise or incomplete information- to the detriment of safety. Life-Saving Equipment Liferafts and Hydrostatic Releases The Lo-Da-Kash carried a four-person inflatable liferaft although it was not required to do so by regulation. Inspection of the liferaft container when retrieved revealed that it had no residual buoyancy. The loss of buoyancy may have been brought about by the accumulation of water inside the liferaft container through the drain holes in the canister while it was submerged. Subsequent testing demonstrated that the raft inflated as designed when the painter line was pulled out. The liferaft may have worked its way out of the cradle because of local tidal currents and underwater pressure compressing the foam rubber cushion on the cradle. While there is no requirement for the carriage and stowage of the liferaft on uninspected fishing vessels, there is information8 available to operators recommending the use of liferafts equipped with deep chocks or a hydrostatic release unit. In occurrences involving small vessels similar to the Lo-Da-Kash, capsizing or foundering typically transpires very quickly, leaving little time for the crew to manually deploy a liferaft. Instances are on record where lives have been lost and the involved liferafts did not provide life-saving support to persons in the water.9 Emergency Position-Indicating Radio Beacons (EPIRBs) The Lo-Da-Kash did not carry an EPIRB, nor was it required to do so by regulation. The Lo-Da-Kash did not have enough time to send a distress message. However, the carriage of an EPIRB would have provided an opportunity to automatically initiate a transmission and to alert search and rescue (SAR) authorities at the onset of the distress, increasing the chances of survival. As a result of its investigation into the sinking of the small fishing vessel BrierMist, the Board recommended (M00-09) that small fishing vessels engaging in coastal voyages be required to carry an EPIRB or other appropriate equipment that floats free, automatically activates, alerts the SAR system, and provides position updates and homing-in capabilities. In response to the recommendation, TC indicated that it continues to support and encourage the voluntary carriage of EPIRBs on all vessels that are not required to carry this equipment. Furthermore, the risk assessment study by TCto evaluate the need for more effective distress-alerting capabilities on small commercial vessels, including fishing vessels that are not yet required to carry either an EPIRB or a VHFradio withDSC, is ongoing. The need to alert authorities in a timely manner and to request assistance in the event of capsizing or foundering has been identified in previous TSB investigations in which delays in reporting distress situations have contributed to the loss of lives. Instances are on record where the carriage of an EPIRB has contributed to the saving of lives.10 TC is introducing new Fishing Vessel Safety Regulations under the Canada Shipping Act, 2001 Regulatory Reform initiative. Numerous consultation sessions have been conducted to discuss the proposed requirements that will apply to small fishing vessels (less than 24m in length). The carriage of EPIRBs has been addressed, and in the latest draft regulations, a vessel like the Lo-Da-Kash would not be required to carry one unless it was considered a vessel of closed construction and it did not carry a coastal liferaft; or the hull of the vessel met the inherent buoyancy criteria as defined in the Small Fishing Vessel Regulations. the added weights above the vessel's centre of gravity from modifications; the ice accretion experienced during the voyage; the free surface effects of liquids in tanks and water shipped and retained on deck; and the fishing gear caught on an obstruction, generating a large heeling moment. the added weights above the vessel's centre of gravity from modifications; the ice accretion experienced during the voyage; the free surface effects of liquids in tanks and water shipped and retained on deck; and the fishing gear caught on an obstruction, generating a large heeling moment. The inherent low freeboard along with the heel permitted water to be shipped and retained on deck, and downflooding ensued through the openings at well deck until all reserve buoyancy was lost and the vessel sank. There is no requirement for a hydrostatic release unit or deep chocks to be fitted on small fishing vessels, and this precluded the liferaft from floating free and deprived the persons in the water of critical life-saving equipment and protection from the elements. Because a distress message was not transmitted and no automatic means of raising an alert was carried, the search and rescue response was delayed, decreasing the possibility of survival.Findings as to Causes and Contributing Factors the added weights above the vessel's centre of gravity from modifications; the ice accretion experienced during the voyage; the free surface effects of liquids in tanks and water shipped and retained on deck; and the fishing gear caught on an obstruction, generating a large heeling moment. the added weights above the vessel's centre of gravity from modifications; the ice accretion experienced during the voyage; the free surface effects of liquids in tanks and water shipped and retained on deck; and the fishing gear caught on an obstruction, generating a large heeling moment. The inherent low freeboard along with the heel permitted water to be shipped and retained on deck, and downflooding ensued through the openings at well deck until all reserve buoyancy was lost and the vessel sank. There is no requirement for a hydrostatic release unit or deep chocks to be fitted on small fishing vessels, and this precluded the liferaft from floating free and deprived the persons in the water of critical life-saving equipment and protection from the elements. Because a distress message was not transmitted and no automatic means of raising an alert was carried, the search and rescue response was delayed, decreasing the possibility of survival. The recently modified vessel entered service without a reliable stability assessment, with no stability data on board for the guidance of the master, and no formal instructions for the safe operation of the fishing gear, nor was there a requirement to do so. For small fishing vessels such as the Lo-Da-Kash not exceeding 15in gross tonnage, there is no requirement for the vessel's stability to be assessed. Following modifications, small fishing vessels are not required to undergo an assessment to ensure that they are safe to operate and that they are suitable for their intended purpose. There are no requirements or criteria regarding the effect of fishing gear on the stability of fishing vessels. The Lo-Da-Kash's departure from Maces Bay, with winds of 25 to 30 knots and freezing spray warnings forecast, exposed the vessel to additional risks.Findings as to Risk The recently modified vessel entered service without a reliable stability assessment, with no stability data on board for the guidance of the master, and no formal instructions for the safe operation of the fishing gear, nor was there a requirement to do so. For small fishing vessels such as the Lo-Da-Kash not exceeding 15in gross tonnage, there is no requirement for the vessel's stability to be assessed. Following modifications, small fishing vessels are not required to undergo an assessment to ensure that they are safe to operate and that they are suitable for their intended purpose. There are no requirements or criteria regarding the effect of fishing gear on the stability of fishing vessels. The Lo-Da-Kash's departure from Maces Bay, with winds of 25 to 30 knots and freezing spray warnings forecast, exposed the vessel to additional risks. Safety Action Taken Carriage of Emergency Position-Indicating Radio Beacons (EPIRBs) In June 2004, the TSB issued a Marine Safety Information (MSI) letter (No.03/04) addressed to Transport Canada (TC) regarding the alerting of vessels in distress and the carriage of emergency position-indicating radio beacons (EPIRBs) in particular. The MSInoted that, given that small fishing vessels are susceptible to sudden capsizing, consideration of this occurrence may benefit the risk assessment study ongoing at the time to evaluate the need for more effective distress-alerting capabilities on small fishing vessels. In response, TC indicated that, in conjunction with its partners, it will continue to encourage and promote the voluntary carriage of equipment capable of sending rapid distress alerts, such as EPIRBs, personal locater beacons, and very high frequency (VHF) radiotelephones fitted with a digital selective calling (DSC) capability. TCrecommended that Industry Canada require that all fixed-type-approved VHFradiotelephones be capable of distress alerting using DSC. As well, TC has various publications in print to hand out to stakeholders at industry-related venues. Float-Free Arrangements for Liferafts In July 2004, the TSB issued Marine Safety Advisory (MSA) 02/04 addressed to TC regarding the carriage of float-free arrangements on uninspected small fishing vessels. The MSA noted the Board's concern that, although TC's impending Regulatory Reform will require that liferafts, when carried, float free, the risks remained in the interim. In response, TC indicated that, in the new proposed Fishing Vessel Safety Regulations, there will be requirements for liferafts, when carried, to have float-free arrangements. In the interim, TC has used a number of methods to communicate the importance of these devices during consultations with the fishing industry as part of the Regulatory Reform project. Assessment of Stability Requirement for Small Fishing Vessels TC issued Ship Safety Bulletin (SSB) 04/06 entitled Safety of Small Fishing Vessels: Information to Owners/Masters about Stability Booklets as an interim measure in advance of the new Fishing Vessel Safety Regulations. The bulletin applies to all owners and operators of fishing vessels, new and existing, that are between 15and 150in gross tonnage and not more than 24.4m in length. It sets out how to determine whether a vessel requires a stability assessment and stability booklet. While this does not pertain to vessels with a gross tonnage of less than 15,owners and operators are being encouraged to review SSB04/06 and determine whether a stability assessment and stability booklet could help them operate safely.